Provider Demographics
NPI:1073017679
Name:MOORE, NICHOLAS M (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:M
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:1653 W CONGRESS PKWY STE 1173
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3833
Mailing Address - Country:US
Mailing Address - Phone:312-942-3214
Mailing Address - Fax:312-942-6787
Practice Address - Street 1:1653 W CONGRESS PKWY STE 1173
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-3214
Practice Address - Fax:312-942-6787
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist